Masters of Their Destinies

There's an old saying, favored by independent, strong-willed types, that "if you want something done right, do it yourself."

At first blush, this approach would seem to run counter to an environment where teamwork is important - but the two philosophies come together nicely at Dublin Primary Care.

When the practice began floundering financially a few years ago, the physicians decided to do it themselves - buying the practice and facilities from an independent practice association (IPA). The result, according to operations manager Deborah Milburn, is "a very cohesive group" that is highly motivated and more financially sound than before.

"One thing that has made all of us a little bit happier is knowing that we're in charge of failures and triumphs," says Peter Clothier, DO. He says the transition from employee to physician-owner in 1999 was an eye-opener.

"We didn't realize the financial drain that the extra layers of administration had on the practice until we bought the practice and the building. One of my personal beefs is that we were being told by some outside entities how to be cost-conscious. Being a physician-owner has made all the difference in the world to me, personally. We're more stimulated and geared to be more productive and improve our incomes because it's coming back to us."

Climate for change

Clothier describes a scenario familiar to many physicians, whether they were part of an IPA in the early '90s, or doing the dot-com scene at decade's end. The group of physicians running the practice "were thought to have deep pockets, but really didn't know how to steer the ship. We were not managing money very well," he recalls.

As corporate belt-tightening became more commonplace, the IPA "decided to divest itself of clinics, and we were given first right of refusal to buy the practice, buy the building, or they'd sell it."

To avoid re-starting their careers from scratch, a group of eight physicians "decided to buy it ourselves. It was a do-or-die type of thing," Clothier says. "Because we already had the physical plant set up, the patient following, the employees, and all the logistics down," it just made sense.

As fellow practice owner Steven Luebbert, a pediatrician, recalls, "A few of [the physicians] were unsure, but then I think the energy ... kind of rubbed off on everybody. That was very positive."

Today, the physicians and their 50 employees have settled into a cohesive pattern of communication and cooperation. Among the physician-owners, "Each person has a voice. We discuss things, sometimes to the point of pain," says Luebbert. "But we make sure there's consensus."

To keep employees in the loop, Milburn says she has staff meetings once a month, or as needed "if there's ever an issue or a problem."

In the early days of the practice, "there was a lot of chaos" before some systems were put into place. Now, Milburn encourages staff to provide input into how their jobs can be made more productive. "You tell me what works and what doesn't work," she tells staff, "and we'll continue to modify until you're happy with it. We can do whatever we want to make it happen - but this is what has to happen, this is the outcome that I expect."

High motivation and volume

The physicians in the practice maintain their own set of expectations and outcomes. "As far as productivity goes, the providers in our office set their own salaries," says Luebbert. "The only thing that has to happen is you have to meet it. Everybody knows that if they don't meet their productivity that they just have to do something to bring it back in line," which might be accomplished by temporarily modifying schedules to see more patients.

The mid-level providers' salaries include productivity-based incentives. Each physician works with the mid-level providers to devise a schedule that works for them. The schedulers then prepare an individualized template for each physician that outlines how many patients he or she can comfortably see in an hour.

"I don't tell somebody, 'You have to see six kids an hour,'" says Luebbert. "I just say do it at a pace where you feel comfortable. Our big issue is quality. We figure that people don't come in the door because an HMO tells them, they're coming in the door because they want to."

This appears to be true, as the practice enjoys a high level of patient loyalty. "Our schedules are full, our patients stay with our doctors," says Milburn.

Generally, thanks to attention to scheduling and a sense of teamwork, things run smoothly, despite the high patient volume. "There will be 600 to 900 calls a day," Milburn adds. "Our telephones have an automated attendant that answers our phones and routes callers to the right place - appointments, referrals, triage. We have three triage nurses on our phones every day for peds and three for family practice. That way they can return calls for the doctors and they can triage the appointments and schedule appropriately. For each physician, we will block so many appointments for routine physicals, so many for same-day, so many for follow-up."

Even within this structured approach, there's room for flexibility. "If the doctor has a complicated case, one of the mid-levels or one of the other doctors can pick up one or two [patients]. That's the teamwork," says Milburn.

 "Generally," Luebbert adds, "we're trying to make it so that when somebody goes to the doctor it's not a hassle. They can get in the system quickly, we can see them quickly, we can get them back to the rest of their day outside of the doctor's office."

Growth and rewards

As the practice grows, the patient following remains strong. Because of high demand, Dublin Primary Care recently opened a new pediatric office in the nearby town of Monument, Colo. It is expected to be on a fast growth track. "It's designed for three providers," says Milburn. "We only have one doctor up there at this point. When [her schedule] is completely full, which we are expecting, we will send a mid-level and then another physician up there. The community is delighted that we're there - she is the only pediatrician in that community."

At the main office in Colorado Springs, the family practice and pediatrics practice "function quite separately, and that's the design of the building," says Milburn. "Exam rooms are on the perimeter of the building with pediatrics on one side, family practice on the other. Then we have shared staff - the policies are the same, everything works the same."

As a whole, that staff, along with the eight physician-owners, are "singing off the same sheet of music. We all have the same goals, we want to be successful and happy and generate a good and faithful following - and we have," says Clothier.

"The bottom line for me is, keep your employees happy. We pay good salaries here, we provide medical care for employees and spouses. We work together to hire employees who are well trained, professional, happy, thinking alike, and who really want to help us move forward in terms of a productive business and a good medical environment."

Milburn agrees that finding the right mix is crucial for a productive, healthy workplace. "The key is the right people working together," she says. When the right balance is achieved, the result is satisfaction all around.

"It's a very friendly office. The doctors and nurses like working here," Luebbert adds. "We try to treat people the way they're supposed to be treated, both as customers and as our office staff."

Clothier takes an even broader view of the group's success. "A lot of folks are discouraging their kids from going in to medical school these days, but if you play your cards right, it's still a very rewarding way to go."

Joanne Tetrault, director of editorial service for Physicians Practice, can be reached at jtetrault@physicianspractice.com.

This article originally appeared in the September/October 2001 issue of Physicians Practice.